Depression Through Chinese Eyes: a window into public mental health in multicultural Australia Bibiana Chan, SPHCM PhD thesis supervisors: Prof. Maurice.

Depression ThroughDepression Through Chinese Eyes: Chinese Eyes:

a window into public a window into public mental health in mental health in

multicultural Australiamulticultural AustraliaBibiana Chan, SPHCM Bibiana Chan, SPHCM

PhD thesis supervisors: Prof. Maurice PhD thesis supervisors: Prof. Maurice Eisenbruch, Prof Gordon Parker, A/Prof Eisenbruch, Prof Gordon Parker, A/Prof

Jan Ritchie Jan Ritchie

Roadmap of presentationRoadmap of presentation

Why study depression?Why study depression? Migration, Acculturation, Transcultural Migration, Acculturation, Transcultural

PsychiatryPsychiatry Cultural Construction of Illness & TCMCultural Construction of Illness & TCM MethodologyMethodology Quan statistical findings & Qual thematic Quan statistical findings & Qual thematic

analysis analysis Cultural Competent Psychiatry Cultural Competent Psychiatry LimitationsLimitations Where do we go from here?Where do we go from here?

Why study depression?Why study depression?

1. 1. WHO named ‘clinical depression’ as the WHO named ‘clinical depression’ as the 22ndnd greatest burden of disease (DIYS) greatest burden of disease (DIYS) Mathers and Loncar, 2006Mathers and Loncar, 2006

2. High prevalence of Major Depression in 2. High prevalence of Major Depression in Western culturesWestern cultures Kessler et al. 1994, 2005.Kessler et al. 1994, 2005.

3. Low prevalence in Chinese at different 3. Low prevalence in Chinese at different sitessites

Chen et al 1993, HK; Hwa et al 1996, Taiwan; Murray & Lopez Chen et al 1993, HK; Hwa et al 1996, Taiwan; Murray & Lopez 1999, Shen et al. 2006, China.1999, Shen et al. 2006, China.

4. 4. Cross-cultural studies: high prevalence Cross-cultural studies: high prevalence Centre w’ low threshold, low prevalence Centre w’ low threshold, low prevalence Centre w’ high thresholdCentre w’ high threshold Simon et al. 2001.Simon et al. 2001.

Help-Help-seekingseeking

Western Culture Chinese Culture

DepressiDepressionon

MigrationAcculturation

Chinese in Sydney

Cultural construction of illnessCultural construction of illness

Kleinman seminal study in Hunan, China in 80s, Kleinman seminal study in Hunan, China in 80s, coined the term ‘coined the term ‘Explanatory Models’. Explanatory Models’.

‘‘Somatisation Vs PsychologisationSomatisation Vs Psychologisation’ (Kirmayer, ’ (Kirmayer, Cheng, Parker)Cheng, Parker)

SJSR gains popularity in 80s but declined in SJSR gains popularity in 80s but declined in 1990s1990s when CCMD-II became widely used in when CCMD-II became widely used in China (Lee & Kleinman 1997)China (Lee & Kleinman 1997)

Body-Mind LinkBody-Mind Link - Conceptualization of - Conceptualization of Depression in Chinese (Ying 2002) Depression in Chinese (Ying 2002)

Examples in other cultures Examples in other cultures (Major Depression, (Major Depression, Evil eyes, Evil eyes, nervos, susto)nervos, susto)

Traditional Chinese MedicineTraditional Chinese Medicine

Harmony and Harmony and Yin/Yang BalanceYin/Yang Balance at cosmological, society, family at cosmological, society, family and individual’s physical leveland individual’s physical level

Body-mind link Excessive EmotionsExcessive Emotions as cause of as cause of

‘illness’ (threaten harmony of ‘illness’ (threaten harmony of ‘group’)‘group’)

‘‘Nourish Life’’ as the long term as the long term goal (c.f. treating acute illness) fit goal (c.f. treating acute illness) fit well with viewing mental illness as well with viewing mental illness as chronic chronic

Pre-migration

Migration

Post-migration

Vu

lner

abil

ity

Res

ilie

nce

AcculturationMental Disorder

Su

pp

ort

Self

Bhugra’s Model

Receiving country

Country of origin

Mixed methods Mixed methods

Quantitative Quantitative ToolsTools Depression stateDepression state

DMI-10DMI-10 AcculturationAcculturation

Suinn-Lew scaleSuinn-Lew scale Self-depression?Self-depression?

Y/N itemY/N item Help-seekingHelp-seeking

5-choice item5-choice item

Qualitative ToolsQualitative Tools A projective testA projective test

2 scenarios, 1F & 1 M2 scenarios, 1F & 1 M AcculturationAcculturation

Suinn-Lew scaleSuinn-Lew scale Self-depression?Self-depression?

Narrative, disclosureNarrative, disclosure Help-seekingHelp-seeking

Narrative, disclosureNarrative, disclosure The meaning of The meaning of

‘emotional ‘emotional distress’ :MDEMSdistress’ :MDEMS

AssumptionsAssumptions Migrants are disposed to Migrants are disposed to high

acculturation stress likely to trigger likely to trigger clinical depression clinical depression

Low acculturated Chinese less familiar Low acculturated Chinese less familiar with Western medical model of with Western medical model of depression, thus in structuring Survey, depression, thus in structuring Survey, avoid pre-disposing informants to one model or another.

No-help sought? (missing data): No-help sought? (missing data): definitive list of possible help-seeking definitive list of possible help-seeking strategies in survey.strategies in survey.

Demographics & Depression (survey group)Demographics & Depression (survey group)

ChineseChinese ControlControlss

Showing degree of Showing degree of acculturationacculturation

LowLow

n= 243n= 243

High High

n = 115n = 115 n = 143n = 143

AgeAge 43.343.3 31.431.4 41.541.5Bachelor DegreeBachelor Degree 21%21% 42%42% 22%22%Not in workforceNot in workforce 39%39% 10%10% 9%9%Age at MigrationAge at Migration 32.832.8 13.813.8 N/AN/ASLASSLAS 2.052.05 2.722.72 N/AN/ADepressive Depressive Episode*Episode*

27.9%27.9% 37.6%37.6% 49.2%49.2%

Episode >4 wk*Episode >4 wk* 14.4%14.4% 16.8%16.8% 28.8%28.8%

Recognition of depressive symptoms Recognition of depressive symptoms among Low-Acc and High-Acc Chineseamong Low-Acc and High-Acc Chinese

Core symptom

s

Depressed, loss of interest, motivation, and helpless

Somatic Symptoms

Insomnia, heaviness in chest, body-ache pain…Salient to Low-Acc Chinese

Non-somatic (Cognitive) Symptoms

Suicidal thoughts, feelings of worthlessness,Salient to High-Acc Chinese

ChineseRecognition

of symptoms

Most Troubling SymptomsMost Troubling Symptoms (self-(self-nominated)nominated)

Low-AccLow-Acc

Chinese Chinese n=71 Weighted n=71 Weighted scorescore

High-AccHigh-Acc

Chinese Chinese n=47 Weighted n=47 Weighted

scorescore

Aust Aust n=65 n=65 Weighted Weighted

scorescore

InsomniaInsomnia 67 (1)67 (1) 20 (2)20 (2) 18(6)18(6)

depressedepressedd

42 (2)42 (2) 39(1)39(1) 24 (5)24 (5)

Anxious & Anxious & tensetense 31 (31 (3)3) 25(5)25(5) 46 (1)46 (1)

XX motivationmotivation

20 (4)20 (4) 27(4)27(4) 29(2)29(2)

withdrawwithdrawnn

18 (5a)18 (5a) 14(6)14(6) 25 (3a)25 (3a)

HopelessHopeless 18 (5b)18 (5b) 11(10)11(10) 10 (11)10 (11)

SadnessSadness 9 (12)9 (12) 29 (3)29 (3) 16 (7)16 (7)

FatigueFatigue 7 (14)7 (14) 20(6)20(6) 25 (3b)25 (3b)

Most nominated EMsMost nominated EMsLow-Low-Acc Acc n=59n=59

High-Acc High-Acc n=44n=44

AustAustn=60n=60

χχ 2 2

df = 2df = 2

Life StressLife Stress 11.911.9 15.915.9 23.323.3 2.822.82Work Work StressStress

16.916.9 15.915.9 8.38.3 2.192.19

RelationshiRelationshipp

15.315.3 22.722.7 20.020.0 0.970.97

Study-Study-relatedrelated

11.911.9 13.613.6 3.33.3 4.014.01

Health-related

10.210.2 4.54.5 20.020.0 6.01*6.01*

Family Challenges

20.320.3 22.722.7 6.76.7 6.21*6.21*

FinanceFinance 6.86.8 9.19.1 1.71.7 2.962.96MigrationMigration 11.911.9 4.54.5 N/AN/A 1.69 1.69 df=1df=1

Episode less than 4 Episode less than 4 weeksweeks

0246

8101214

161820

X GP Rx Psy't Herb't F/F

C-Chin

C-Eng

Control

No. of Inform’t

Episode more than 4 Episode more than 4 weeksweeks

0

10

20

30

40

50

60

70

80

X GP Rx Psy't Herb't F/F

C-Chin

C-Eng

Control

%

Diagrammatic representation of the detail help-seeking pathway of

Low-Acc Chinese.

(1)Herbalist

Only

(2) Rx

(1)Rx

Low-Acc Chinese (n = 47)

(13)No help(34) Help Sought

(5) Informal Help (30) Prof Help

(3)Herbalist (24) GPs(12) Psychologist

(7) Specialist (17)No-specialist

(5) Anti-Depressant

(2) No Anti-Depressant

(2) Anti-Depressant

(15) No Anti-Depressant

(2)(2)Anti-Depressant

(3) No Anti-Depressant

(2)Rx(1)

Rx

(1)

(4) no Otherhelp

(1)(1)

Help-seeking PuzzleHelp-seeking Puzzle

Self-helpFamily

& Friends

Cultural

ValuesSpiritual

Chinese

Medicine

GP

Psycho Therapy

Counselling

Community

Support

Psychiatrist

Normalize Depression

Multisectoral Collaborat’n

Em

powerm

entof consum

ers

Reco

gn

ition

of

pro

fessio

nal h

elp

Lay Illness ConceptLay Illness ConceptSick in the body

Unwell in the mind

Permanentserious

Attacked by pathogens

Mental Illness

Psychological Mind State

EmotionalUps & Downs

ImbalanceNot Physical

SJSR

Schizophrenia

ManicDepressives

Highly Stigmatized

Start to attract stigmaSelf-talk, suicidal

Mad,

Crazy Violent, out

of control

Could snap out

Short course

Could get worse

Could it be SJSR?

ImplicationsImplications ((a) If Chinese are good at recognising symptoms how can they be

encouraged to

report these symptoms to their doctors? (b) If Chinese GPs are the first port of call in many

depression cases, how can GPs be better equipped to make accurate diagnoses?

(c) If Low-Acc Chinese are more likely to talk about emotional distress with Chinese herbalists, how will these herbalists then refer their patients to mainstream mental health services?

(d) Focus group informants expressed their wish to learn more about clinical depression and its treatment.

Cultural Competent Cultural Competent PsychiatryPsychiatry

Health system

(doctors, hospitals

, etc)

Culturally Competen

tPsychiatr

y

Chinese GPs &

Herbalists

Psychotherapy Counselling, CBT* & Family Therapy

referral

Support groups,

Community services

Socio-culturalSupportFamily &Friends

Where do we go from Where do we go from here?here?

Population mental health – suicide Population mental health – suicide prevention & health promotion (c.f. prevention & health promotion (c.f. infant immunization)infant immunization)

Normalisation & de-stigmatization – given Normalisation & de-stigmatization – given permission to talk about negative emotionspermission to talk about negative emotions

Building social capital (resilience, family and Building social capital (resilience, family and cultural values, social inclusion & consumer cultural values, social inclusion & consumer participation)participation)

Holistic approach – healthy person, healthy Holistic approach – healthy person, healthy family, healthy school/work place and health family, healthy school/work place and health society society

Evaluation of Cultural Competency in practiceEvaluation of Cultural Competency in practice

AcknowledgementAcknowledgement All professional & lay helpers who walked along the journey of recovery with me. NHMRC for the funding to make this research possible. My research supervisors Professor Maurice Eisenbruch, Professor Gordon Parker, A/Professor Jan Ritchie for their intellectual input. All participating GPs, Chinese herbalists, medical centres, and community organizations to facilitate data collection.